Robert P. Dunbar

Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns.

Objectives: Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern. Design: Retrospective chart and radiographic review. Setting: Urban Level 1 university trauma center. Patients: Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group. Main Outcome Measure: Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA). Results: Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system. Conclusions: A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.

Failure of fracture plate fixation.

&NA; Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft‐tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjuction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full‐length constructs should be considered for osteoporotic fractures.

Early limited internal fixation of diaphyseal extensions in select pilon fractures: upgrading AO/OTA type C fractures to AO/OTA type B.

Fractures of the tibial pilon may present an array of problems and potential complications. Staged treatment with initial spanning external fixation of the ankle has proven to be a successful strategy for the treatment of these difficult fractures in many cases. A subset of the tibial pilon fractures, with an oblique extension to the diaphysis may constitute a treatment problem, as these long fractures may be difficult to reduce at the time of definitive fixation, often 1-3 weeks post-injury due to interposed soft tissues, hematoma and/or early callus. Anatomic reduction of this fracture may thus require more extensive dissection than might be desirable in this injury. We offer a technique to assist in the treatment of the subset of these difficult fractures. In appropriate cases, a small fragment plate may be applied to the diaphyseal component of the fracture in an anti-glide type plate application, through a small incision proximal to the area of greatest injury. This re-establishes the length, rotation and alignment of this fragment which is commonly attached to either the Chaput anterolateral or the Volkmann posterolateral fragment. It additionally provides the intimate contact that may favor early union or minimize the need for secondary procedures. The fracture is thereby converted from a complete articular AO/OTA 43-C type pattern to a partial articular, or AO/OTA 43-B type pattern.

A staged treatment plan for the management of Type II and Type IIIA open calcaneus fractures.

Objective: To assess the results of a standardized staged treatment strategy for displaced open calcaneal fractures with medial wounds. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Fourteen displaced open Type II or Type IIIA Orthopaedic Trauma Association (OTA) 73 Type B or C calcaneal fractures treated between January 2000 and December 2007 who were managed with a standardized regimen. Intervention: Patients were treated in a staged fashion with antibiotics, irrigation, débridement, and percutaneous Kirschner wire fixation followed by definitive open reduction and internal fixation when soft tissues were amenable to fixation. Main Outcome Measures: Data regarding demographics, injury characteristics, time to fixation, interventions, and treatment complications were documented. The complication rate, time to bony union, and additional procedures were determined. Results: There were four OTA 73B and 10 OTA 73C injuries with open Type II or Type IIIA wounds on the medial side. All patients had débridement, irrigation, and percutaneous fixation within 8 hours of presentation. Definitive fixation was carried out on average 18 days after initial presentation with 10 patients only requiring the initial débridement and stabilization procedure followed by definitive fixation All 14 patients underwent definitive fixation through an extensile lateral approach. A superficial infection developed in one patient and a deep infection in one patient. All patients went on to union at an average follow up of 19 months. Conclusion: Open Type II and IIA wounds associated with displaced OTA Type 73 B or C calcaneal fractures represent high-energy injuries with potential increased risk for wound complications. In our series, a staged treatment strategy consisting of urgent débridement, provisional internal stabilization, and late definitive reconstruction offers a protocol that may reduce infections associated with open calcaneal fractures.

The use of surgical drains in orthopedics.

The use of postsurgical drains have a long history in thoracic and abdominal surgery. In orthopedics these devices have been used to decrease local edema, lessen the potential for hematoma or seroma formation, and to aid in the efflux of infection. However, the role of postoperative surgical drains in clean, elective cases has not been firmly established. In fact, most studies fail to show a statistical difference in outcome between drained and undrained patients. Despite the paucity of clinical evidence demonstrating any benefit supporting their use, drains continue to be placed after elective orthopedic procedures.

Intramedullary Fixation of Fibular Fractures Associated With Pilon Fractures

Objectives: The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures. Design: Retrospective study. Setting: Level I university trauma center. Patients/Participants: From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months. Intervention: A retrospective chart and radiograph review was conducted of all patients for data extraction. Main Outcome Measurements: Fibular fixation type and length, fibular healing, and complications. Results: Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3° of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1° in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months. Conclusions: In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Entrapped Posteromedial Structures in Pilon Fractures

Objectives: To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures. Design: Retrospective cohort review. Setting: Regional Level 1 Trauma Center. Patients/Participants: About 394 patients with 420 pilon fractures treated between January 2005 and November 2011. Intervention: Each patients preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture. Main Outcome Measurements: Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure. Results: 40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%). Conclusions: In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Technique Tip: Use of “Pie Crusting” of the Dorsal Skin in Severe Foot Injury:

Severe foot trauma has been shown to have a significant effect on patient outcomes.6–8 The appropriate and timely use of modern operative techniques in the treatment of fractures and dislocations in the feet has been shown to improve outcomes.2 Because such operative procedures are contingent upon having a soft-tissue envelope that is conducive to operative fixation, the use of more biological or soft-tissue friendly techniques is advised. Techniques that respect the soft tissues are believed to minimize devastating complications and may improve fracture healing and, thus, overall function. As with other areas of the body, high-energy injuries to the foot may carry with them a risk of compartment syndrome. Failure to promptly and completely treat elevated intracompartmental pressure commonly leads to significant morbidity.4 Compartment syndrome can be devastating, with the best treatment remaining early diagnosis and avoidance of ischemic complications. Decompressive dermatofasciotomies for compartment syndrome of the foot have been previously described.4 One problem with complete fasciotomies of the foot is that the underlying closed fractures and dislocations effectively become directly exposed open fractures. Typically, these fasciotomy wounds retract because of associated local edema. Commonly, days elapse before the skin can be closed or grafted. In this time, the tissues often are colonized with microorganisms. Thus, these already severely injured tissues, now exposed, are at increased risk for infection when definitive operative fixation is undertaken. The time required until wound closure or skin graft maturity also may make reconstruction more difficult, which may require

Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls.

Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection. Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Fluoroscopically guided hip capsulotomy: effective or not? A cadaveric study.

Objective: The purpose of this study was to examine the efficacy of a fluoroscopically guided hip capsulotomy. Methods: Ten fresh-frozen paired cadaveric hips were injected under fluoroscopic guidance with saline sufficient to generate an intra-articular pressure greater than 58 mmHg. The pressure was monitored continuously using a percutaneous transducer. A limited lateral approach to the proximal femur was performed by one of two senior orthopaedic trauma surgeons. Using a scalpel under fluoroscopic guidance, each surgeon made one attempt at an anterior capsulotomy. Changes in intra-articular pressure were recorded throughout the procedure. The specimens were then dissected to measure the extent of each capsulotomy as well as the distance from the capsulotomy to nearby neurovascular structures. Results: A rapid and substantial decrease in intra-articular pressure was seen in all hips. The mean intra-articular pressure postcapsulotomy was 8.4 mmHg. The capsulotomies averaged 15.1 mm in length. None of the attempts at capsulotomy lasted longer than 90 seconds. The average distance between capsulotomy and the lateral-most branch of the femoral nerve was 19.5 mm. The femoral artery was on average 40.3 mm from the capsulotomy. There was no correlation between the side on which capsulotomy was performed and its extent or proximity to neurovascular structures. Conclusions: Fluoroscopically guided hip capsulotomy through a small lateral incision appears to be a safe, effective, and expedient method, which may substantially reduce intra-articular pressure after minimally displaced femoral neck fractures.